The Jack Brewer Foundation’s
Post Release Application
Participant Application
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
EC#
DC#
*
Address
Street Address
County
City
State / Province
Postal / Zip Code
SS Number (Last 4 Digits)
Date of Birth
-
Month
-
Day
Year
Date
Age
Email
example@example.com
Phone
Please enter a valid phone number.
Are you currently, or will you upon release, be considered the biological, custodial, legal, adoptive, foster or stepfather, grandfather, non-relative male, or male family member serving in a Father role of a child or children 17 y/o or younger, living in the state of Florida?
Yes
No
Marital Status:
Married
Single
Divorced
Separated
Widower
Did you grow up with an active father?
Yes
No
Did your father consistently tell you heloved you while you were growing up?
Yes
No
Number of Children (Total number of children aged 17 & under):
*
Have you ever lived in residential re-entry, recovery, or halfway housing, or are you currently residing in any of these types of facilities?
Yes
No
If yes, where?
Where do you live now? Legal Address:
Street Address
County
City
State / Province
Postal / Zip Code
What is your source of income?
Please Select
SSI
SSD
SNAP
TANF
Employed
Unemployed
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Are you in contact with your children?
Yes
No
Do you want to be in contact with you children?
Yes
No
With whom do your minor children currently reside?
With whom do your minor children currently reside?
Unsure
Guardian Name:
Guardian Address?
Street Address
County
City
State / Province
Postal / Zip Code
Education level of Adult children
Unsure
List out the education level of the Children's
*
Do you have an open child support case?
Yes
No
Unsure
Were you convicted of a crime as a youth offender (17 or younger)?
Yes
No
Have you ever been arrested for a sex crime or Arson?
Yes
No
Have you ever been convicted of a gun-related crime?
Yes
No
Have you been, or are you currently, affiliated with a gang?
Yes
No
Probation/Parole?
Yes
No
Start Date
-
Month
-
Day
Year
Probation/Parole
End Date
-
Month
-
Day
Year
Probation/Parole
P.O. Name
P.O. Phone Number
Please enter a valid phone number.
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Are there any court orders, child or family visitation restrictions?
Yes
No
If yes, please explain.
Do you have any abuse/neglect cases with the Department of Children and Families?
Yes
No
If yes, please explain.
Family/Emergency Contact
Emergency Contact Name
Phone
Please enter a valid phone number.
Emergency Current Address
Street Address
County
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone
Please enter a valid phone number.
Are you currently In contact with any of your family?
Yes
No
If so, please explain:
What is the Frequency and method of communication with family members?
No contact
Daily
Weekly
Bi-weekly
Monthly
Yearly
Method of contact
Mail
Letter
Phone
Do you currently receive visits from family? (In person visitation)
Yes
No
If so, please explain:
Are you currently taking any prescription medications?
Yes
No
Choose Not to Disclose
If so, please explain:
Have you been addicted to illegal substances in the past, or are you currently struggling with addiction?
Yes
No
Choose Not to Disclose
If yes, write the Date of last use and Drug of Choice:
Have you experienced relapse?
Yes
No
Choose Not to Disclose
If yes, how many times?
Do you have any compulsive behaviors?
Yes
No
Choose Not to Disclose
What difficulties have been caused by your addictions?
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Have you ever received a DUI?
Yes
No
If so, How many?
Do you struggle with following rulesor respecting authority?
Yes
No
Do you have any biases or prejudices against certain groups or races?
Yes
No
Have you experienced or are you currently experiencing suicidal thoughts?
Yes
No
If yes, have you thought of a plan?
If you answered yes to the previous suicide questions, do you agree to enter into a plan of action/safety if needed?
Yes
No
Choose Not to Disclose
Currently employed?
Yes
No
If yes, name of company:
Employer Address
Street Address
County
City
State / Province
Postal / Zip Code
Supervisor's Name
Supervisor's Phone Number
Please enter a valid phone number.
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Enrolled in college/University?
Yes
No
If yes, Days in Attendance:
Medical Concerns?
Yes
No
Choose Not to Disclose
If so, please explain :
Does your immediate family currently receive government assistance?
None
Unsure
SSI
SSD
SNAP
Medicaid
TANF
Other
Does your immediate family need additional assistance with food, clothing, or shelter?
Yes
No
Unsure
Do you feel your immediate family would participate in parenting class and other family focused development programs?
Yes
No
Unsure
Are you currently enrolled in Continuum of Care (COC) Programming?
Yes
No
Unsure
Have you ever given your life to Christ?
Yes
No
If so, date:
-
Month
-
Day
Year
Date
Have you ever been baptized?
Yes
No
If so, Baptism date:
-
Month
-
Day
Year
Date
Do you have a testimony?
Yes
No
If so, what is your testimony?:
Are you a Veteran?
Yes
No
If yes, branch
Please Select
USAF
USARMY
USCG
USMC
USNAVY
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Education Level
High School
Please Select
Yes
No
Drop-out
If yes, High School completion date:
-
Month
-
Day
Year
Date
GED
Please Select
Yes
No
Inprogress
If yes, GED completion date:
-
Month
-
Day
Year
Date
College
Please Select
Yes
No
Drop-out
If yes, College completion date:
-
Month
-
Day
Year
Date
Professional Skills:
Please Select
Landscaping
Painting
Construction
Debris/Waste Removal
Carpentry
Chef
Driver
Other
If other Profession please mention:
Degrees/Certifications/ Licenses:
Do you have any sports history?
Yes
No
If so, please write the Sports History:
Do you have any arts and entertainment history?
Yes
No
If so, please write the arts and entertainment History:
Have you been incarcerated multiple times (prison & jail) ?
Yes
No
Unsure
How many times:
Have any of your family members been incarcerated?
Yes
No
Unsure
If so, please explain:
Do you need help with the following
Cell Phone
Shoes
Clothing
Food
Shelter
Other
If other need Please Explain:
Felony convictions?
Yes
No
If so, please explain:
Felony convictions
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Do you own a car?
Yes
No
Do you have a current driver's license?
Yes
No
Do you have a Bank Account?
Yes
No
Do you have access to reliable transportation?
Yes
No
Have you ever participated in anger management, mental health, substance abuse, or addiction treatment?
Yes
No
Choose Not to Disclose
If so, please explain:
Are you currently enrolled in post release program?
Yes
No
Name of the program:
Contact person:
Email
example@example.com
Phone
Please enter a valid phone number.
Preferred Language for Speaking and Writing:
English
Spanish
Portuguese
Creole
Other
If other, please explain:
Participant Signature
Date
-
Month
-
Day
Year
STAFF USE ONLY
Applicant Accepted
Yes
No
Staff Signature
Date
-
Month
-
Day
Year
Submit
Should be Empty: